KEY POINTS:
Twelve patients under the care of Waitemata District Health Board's mental health service took their own lives in one year.
In the preceding year there were five suicides and in this financial year, starting July 1, there have been three.
Most of the 20 deaths - which included patients from forensic and drug-and-alcohol services - were community patients.
The figures were disclosed this week in the reports by health boards nationally on "serious and sentinel events" in all of their services.
Simultaneously, the first national tally of such events, by the Quality Improvement Committee, reported that 182 hospital patients suffered serious, preventable events in the last financial year. Forty-two of them died.
The day after these revelations, the Auckland health board released part of an external review that strongly criticised its mental health service after four deaths last year.
The general manager of Waitemata's mental health service, Helen Wood, said it ran the country's largest such service, seeing nearly 20,000 patients a year, including many from throughout the Auckland region.
After reviews, it had made a number of changes including a big increase in the training around assessing the risks posed by patients, improved communication with other services when patients were transferred, and improving the response for patients who suffered an after-hours crisis in the community.
The Health Ministry's director of mental health, Dr David Chaplow, said he did not have details of the 12 Waitemata suicides in 2006-07, so could not judge if it was a high number.
Nationally, about 25 patients under compulsory treatment committed suicide each year, mostly in the community and only occasionally in mental health units.
WHAT WENT WRONG
* Factors identified by the Waitemata District Health Board review of patient suicides included:
* Shortage of psychiatrists in 2005-06.
* Poor communication between different shifts of staff.
* Tardy follow-up.
* Difficulty managing patients who were also under another health board.
